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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UJOROUND STORAGE TANK PROGRAM . FEE WORKSHEE <br /> t SITE NAME <br /> FACILITY CONTACT NAME SLC K N.�►�}v <br /> �'e kMACjTieucl<( s �Kubav� r+^or2s� <br /> rACILITY ADDRESS '"�w <br /> 3�J S t. MUwt�oR SITE PHONE # with AREA CODE <br /> 52.4-L�.G 53 <br /> T CITY <br /> Y STATE ZIP CODE # of TANKS <br /> S GUGICYO <br /> N C4 at SITE Z <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> P So�tco6�Ilz� <br /> L INtG2$ <br /> 1 MAILING ADDRESS <br /> G APPLICANT PHONE # WITH AREA CODE <br /> 43� w . ��l��}t <br /> A C� SA4-(WrY <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T �Lbn s�'a MA et s3 �.••1 CLOSURE, INSTALLATION, etc eL0S UXL-Z <br /> A J TOTAL <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) • $100 � i�� 1986 1987 1988 1989 1990 <br /> 1 <br /> E TANK FEE = 150.00/TANK (prior to J+awary 1,A. 1j' ' 0 70/TANK (after January 1, 1991) $ ODS <br /> F # Tanks = _L 1986 1987 <br /> A (multiply # by fee for 'R nI ,1991 1992 1993 1994 1995 1996 <br /> C each year applicable) <br /> L STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) <br /> I See Califorri i'sy%8/8 S Code, Section 25287 <br /> T # Tanks_,y x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> cro <br /> C PERMANENT CLOSURE (Removal or Authorized Closure•In-Place) TANK I.D. #(s) <br /> L CLOSURE FEE • $53.00 per hour (3 hours minimm per TANK) # TANK(s)_ X 1159.00 • 3/ Q <br /> 0 S o <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> R _ <br /> E TEMPORARY CLOSURE FEE • $150.00 each TANK # TANK(s) X- $150.00 <br /> $ <br /> P PLAN CHECK (Install. Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minima per Facility) _ $424.00 minima <br /> 1 <br /> R REPAIR FEE (workplan review 8 construction inspections) <br /> E TANK I.D. #(s) <br /> P TANK REPAIR FEE _ $53.00 per hour (3 hours minima/TANK) # TANK(s) X $159.00 <br /> —_ S 1 <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minima per facility • $159.00) <br /> S <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION <br /> 1 SAMPLING INSPECTION <br /> S <br /> C FEE • 553.00/hr FEE = 553.00/hr <br /> FEE = S 53.00/hr <br /> rt7 OGPF�' %`/r!D �J(+.a'! Ps /Grp �.?OOaD <br /> TOTAL DUE f J 8 <br /> OFFICE USE ONLY <br /> .................................... <br /> Tq <br /> p.:: . j .0 1.3 <br /> � o' <br /> :arrrMsaraw.asrra•aawarasr.•r=•wwrarrwaraYiasir ='airaw�ar:�w:�ps JSrisa •� '�"�['°°"'""�c"" rwr'sas <br /> .......... .........a <br /> EH 23 1132 (REV 1/10/91) ft Pace 11 <br />